Probability of walking in children with cerebral palsy in Europe

Three-Dimensional Instrumented Gait Analysis for Children With Cerebral Palsy: An Evidence-Based Clinical Practice Guideline

BACKGROUND

Children with cerebral palsy (CP) who walk have complex gait patterns and deviations often requiring physical therapy (PT)/medical/surgical interventions. Walking in children with CP can be assessed with 3-dimensional instrumented gait analysis (3D-IGA) providing kinematics (joint angles), kinetics (joint moments/powers), and muscle activity.

PURPOSE

This clinical practice guideline provides PTs, physicians, and associated clinicians involved in the care of children with CP, with 7 action statements on when and how 3D-IGA can inform clinical assessments and potential interventions. It links the action statement grades with specific levels of evidence based on a critical appraisal of the literature.

CONCLUSIONS

This clinical practice guideline addresses 3D-IGA's utility to inform surgical and non-surgical interventions, to identify gait deviations among segments/joints and planes and to evaluate the effectiveness of interventions. Best practice statements provide guidance for clinicians about the preferred characteristics of 3D-IGA laboratories including instrumentation, staffing, and reporting practices.Video Abstract: Supplemental digital content available at http://links.lww.com/PPT/A524.

The effects of power exercises on body structure and function, activity and participation in children with cerebral palsy: an ICF-based systematic review

PURPOSE

To systematically review the literature for evidence of effectiveness of power exercises on physical, physiological, and functional outcomes in children and adolescents with cerebral palsy (CP).

MATERIALS AND METHODS

Methodological quality and evidence synthesis were assessed with using the Cochrane Risk of Bias (RoB) Tools and Modified Bakker Scale. Using the International Classification of Functioning (ICF), outcome measures for muscle agriculture, gait, balance, motor function, aerobic/anaerobic fitness, daily living, mobility, and school participation were categorised.

RESULTS

The overall RoB of four randomised clinical trials was low, one had some concerns and two were rated as high. Moderate evidence was found that power exercises increased walking speed, activities of daily living, muscle strength, and enhanced gross motor function more than a routine physical therapy program.

CONCLUSIONS

The lack of stronger evidence for power training interventions to improve muscle architecture, muscle function, walking capacity, and mobility in children with CP might be explained by the differences in training protocols and degree to which these meet the physiological definition of power, different methods of measuring power, limited durations of training, and the relative effectiveness of control interventions. Future studies should include a stronger focus on child and family-centred participation goals.Implications For RehabilitationPower training can improve gross motor function, walking speed, muscle strength, and activities of daily living more than routine physical therapy.Results comparing power training versus traditional strength training were less pronounced likely because both are intensive and may have positive effects.More research is needed to investigate effects of power training on participation.

Prevalence of cerebral palsy comorbidities in China: a systematic review and meta-analysis

Objectives

This systematic review aimed to comprehensively understand the comorbidity of cerebral palsy (CP) in China.

Methods

We searched through databases in both Chinese and English until December 2022 to gather cross-sectional studies on the comorbidity of CP in China. After two reviewers independently screened the articles, collected the data, and assessed the bias risk, a meta-analysis was conducted using the Stata 17.0 software.

Results

A total of 73 articles were included. Of these, 16 articles reported total comorbidity, with a prevalence of 79.7% (95% CI: 73.8-85.7%); 56 articles reported epilepsy, with a prevalence of 17.9% (95% CI: 15.4-20.4%); 48 articles reported intellectual disability, with a prevalence of 58.0% (95% CI: 51.8-64.3%); 32 articles reported speech disorders, with a prevalence of 48.0% (95% CI: 41.6-54.4%); 41 articles reported hearing disorders, with a prevalence of 17.2% (95% CI: 13.0-21.4%); and 35 articles reported vision disorders, with a prevalence of 23.1% (95% CI: 16.3-29.8%). The topographical type of CP was the primary source of heterogeneity in the prevalence of epilepsy. Diagnostic criteria for CP, clinical type of CP, GMFCS, publishing time, and topographical type of CP were the primary sources of heterogeneity in the prevalence of intellectual disability. Clinical type of CP and topographical type were the primary sources of heterogeneity in the prevalence of speech disorders. Finally, the region was the primary source of heterogeneity in the prevalence of hearing disorders.

Conclusion

The prevalence of comorbidities in CP is high in China. Comorbidities are related to the characteristics, severity, and risk factors of brain insult and have a particular relationship with regional economic development and medical and health levels.

Quantifying States and Transitions of Emerging Postural Control for Children Not Yet Able to Sit Independently

Objective, quantitative postural data is limited for individuals who are non-ambulatory, especially for those who have not yet developed trunk control for sitting. There are no gold standard measurements to monitor the emergence of upright trunk control. Quantification of intermediate levels of postural control is critically needed to improve research and intervention for these individuals. Accelerometers and video were used to record postural alignment and stability for eight children with severe cerebral palsy aged 2 to 13 years, under two conditions, seated on a bench with only pelvic support and with additional thoracic support. This study developed an algorithm to classify vertical alignment and states of upright control; Stable, Wobble, Collapse, Rise and Fall from accelerometer data. Next, a Markov chain model was created to calculate a normative score for postural state and transition for each participant with each level of support. This tool allowed quantification of behaviors previously not captured in adult-based postural sway measures. Histogram and video recordings were used to confirm the output of the algorithm. Together, this tool revealed that providing external support allowed all participants: (1) to increase their time spent in the Stable state, and (2) to reduce the frequency of transitions between states. Furthermore, all participants except one showed improved state and transition scores when given external support.

The Use of the 6MWT for Rehabilitation in Children with Cerebral Palsy: A Narrative Review

Assessing and improving walking abilities is considered one of the most important functional goals of physical therapy in children with cerebral palsy. However, there is still a gap in knowledge regarding the efficacy of treatment targeting the walking capacity of children with CP, as well as their responsiveness to the treatment. The 6 min walk test (6MWT) is a reliable tool to measure this function in children with CP, although less has been known about its potential efficacy to assess changes in the walking abilities associated with interventions. The aim of the present narrative review is to increase the amount of knowledge regarding the use of the 6MWT as a reliable measure to evaluate the effect of interventions on walking capacity in children with CP.

Effectiveness of virtual reality on functional mobility during treadmill training in children with cerebral palsy: a single-blind, two-arm parallel group randomised clinical trial (VirtWalkCP Project)

INTRODUCTION

Treadmill training and virtual reality have been investigated in children with cerebral palsy. However, few studies have assessed the effectiveness of the combination of both treatments on children's functional and balance activities. The project aims to compare the effects of treadmill training with and without virtual reality on walking endurance and speed, static and dynamic balance, gross motor function, functional independence, quality of life and occupational participation in children with spastic cerebral palsy between the ages of 4 and 12 years classified at levels I, II and III of the Gross Motor Function Classification System.

METHODS AND ANALYSIS

This study is a single-blind, two-arm parallel group, randomised, controlled clinical trial. Participants will be recruited at the Pediatric Department of the Vic Hospital Consortium, and the research will be conducted at the University of Vic - Central University of Catalonia. The participants will be randomly allocated into two groups: (1) the experimental group, which will receive the treadmill training at the same time as the virtual reality; and (2) the control group, which will undertake treadmill gait training alone. The training will be provided in 10 sessions over 2 weeks with 30 min for each session. Assessments will be performed on three occasions: 1 week before the intervention, 1 week following the intervention and 1 month after the end of the intervention. The evaluations will involve the 6 min walk test, stabilometry, the Berg Balance Scale, the 10 m walk test, the Gross Motor Function Measure, the Functional Independence Measure, the paediatric quality of life inventory and the Children Participation Questionnaire. For between-within group comparison, a mixed-effect linear model will be used.

ETHICS AND DISSEMINATION

The study has been approved by the Clinical Research Ethics Committee of the Osona Foundation for Health Research and Education (2021061). Results will be published in peer-reviewed journals and presented at international conferences.

TRIAL REGISTRATION NUMBER

NCT05131724.

Reliability and discriminant validity of the quantitative timed up and go in typically developing children and children with cerebral palsy GMFCS levels I-II

PURPOSE

The purpose of this study was to examine the reliability, and discriminant validity of the Quantitative Timed up and Go (QTUG) in typically developing (TD) children and children with cerebral palsy (CP).

METHODS

Twenty-eight TD children and 8 with CP (GMFCS I-II) completed 3 TUG trials while wearing QTUG sensors. Test-retest reliability and discriminative ability were examined for the 57 constituent parameters of the TUG. Relationships between age and these parameters were also examined.

RESULTS

Forty-four of the parameters demonstrated moderate to excellent test-retest reliability, with measures of angular velocity being the most reliable. Twenty-six parameters were different between TD children and those with CP, and twenty-eight gait parameters demonstrated correlations with age, further supporting its discriminative ability.

CONCLUSION

The QTUG is a clinically feasible tool that is capable of both reliably measuring and discriminating many of the movement parameters with the TUG mobility task in TD children and those with CP GMFCS I-II. The results of the present study provide preliminary evidence that the QTUG can discriminate between children on several of the gait parameters within the TUG.

Assessment of gait quality and efficiency after undergoing a single-event multilevel surgery in children with cerebral palsy presenting an intoeing gait pattern

PURPOSE

The biomechanical impact of undergoing a single-event multilevel surgery (SEMLS) for children with cerebral palsy (CP) presenting an intoeing gait pattern has been widely documented. However, past studies mostly focused on gait quality rather than efficiency. Thus, there is a need to determine the impact of undergoing a SEMLS on gait quality and efficiency in children with CP presenting an intoeing gait pattern.

METHODS

Data from 16 children with CP presenting an intoeing gait pattern who underwent a SEMLS were retrospectively selected. Gait kinematics was quantified before (baseline) and at least 1 year after the surgery (follow-up). Gait quality was investigated with the Gait Profile Score (GPS), hip internal rotation angle and foot progression angle (FPA). Gait efficiency was analysed using clinically accessible variables, namely the normalised gait speed and medio-lateral and vertical centre of mass excursions (COMp). Dependent variables were compared between sessions with paired t-tests.

RESULTS

At the follow-up, children with CP exhibited a more outward FPA and GPS as well as a decreased hip internal rotation angle. No changes in normalised gait speed and vertical COMp excursion were observed, and medio-lateral COMp excursion was slightly decreased.

CONCLUSION

Children with CP presenting an intoeing gait pattern who underwent a SEMLS exhibited an increased gait quality, but gait efficiency was only minimally improved at the follow-up compared to baseline. Further studies are needed to identify contributors of gait efficiency in children with CP, and the best treatment modalities to optimise both their gait quality and efficiency.

Motor Functioning and Intelligence Quotient in Paediatric Survivors of a Fossa Posterior Tumor Following a Multidisciplinary Rehabilitation Program

BACKGROUND

Short- and long-term consequences after treatment for childhood fossa posterior tumors are extensively reported in the literature; however, papers highlighting physical function throughout rehabilitation and its correlation with Intelligence Quotient (IQ) are sparse. This study aims to describe the physical functioning and IQ of these survivors, their progression during rehabilitation, and the association with histopathological tumor classification. Additionally, the correlation between gross motor functioning and cognitive functioning was investigated.

METHODS

This retrospective single-center cohort study included 56 children (35 (62.5%) males and 21 (37.5%) females, with an average age of 6.51 years (SD 4.13)) who followed a multidisciplinary program at the Child Rehabilitation Centre, Ghent University Hospital in the period from 2005 to 2020. Descriptive statistical analysis was performed with the use of non-parametric tests and linear regression to determine the relationship between gross motor functioning and IQ.

RESULTS

This report shows impaired motor and intelligence performance in children with a fossa posterior tumor. Although multidisciplinary rehabilitation is beneficial, it is not able to counteract the further decline of several motor skills and intelligence during oncological treatment, more specifically in children with a medulloblastoma. A correlation between gross motor function and total IQ was found.

CONCLUSION

Pediatric survivors of a fossa posterior tumor experience impaired physical and intellectual functions, with more decline during oncological treatment despite simultaneous multidisciplinary rehabilitation.

Acquisition and loss of best walking skills in children and young people with bilateral cerebral palsy

AIM

To explore factors predicting acquisition and loss of best walking ability in young people with bilateral cerebral palsy (CP).

METHOD

In our population cohort (Study of Hips And Physical Experience) of 338 children (201 males, 137 females) with bilateral CP, age at achieving walking was recorded and walking ability predicted from early motor milestones. Walking was assessed at 5 to 8 years (mean 7y) and in 228 of 278 survivors at 13 to 19 years (mean 16y). Parent carers reported their view of any loss of best achieved walking. Factors potentially associated with loss of best achieved walking were explored: severity and type of motor disorder; intellect and communication; manipulative skill; general health and comorbidity; pain; orthopaedic surgery; musculoskeletal spine and lower limb deformity; weight; fatigue; mood; and presence of regular exercise regime.

RESULTS

The ability to walk independently was reliably predicted by the motor milestone 'getting to sit and maintain sitting' by the age of 36 months (without aids) and 55 months (with aids). Forty-five per cent of the cohort never walked 10 steps independently. Not all who achieved walking without aids were still doing so by a mean age of 16 years, which was associated with later age at achieving walking and the degree of musculoskeletal deformity, as was the parent carers' report of loss of best walking.

INTERPRETATION

In this study, development of musculoskeletal deformity was a significant factor in not maintaining best achieved walking by mean age 16 years, which is most likely to occur in young people whose walking ability is with aids over short distances or in therapy only. Prediction of future walking ability in a child with bilateral CP can be made from early motor milestones.

Moderate effect of ankle foot orthosis versus ground reaction ankle foot orthosis on balance in children with diplegic cerebral palsy

BACKGROUND

The children with diplegic cerebral palsy (CP) commonly have abnormal alignment of lower extremities affecting their abilities of keeping balance. Orthoses are one of the many approaches that can be prescribed to improve balance and walking in diplegic children.

OBJECTIVE

This study was conducted to assess the moderate effect of solid ankle foot orthosis (AFO) vs. the ground reaction ankle foot orthosis (GRAFO) on balance in children with diplegic CP.

STUDY DESIGN

A randomized controlled trial.

METHODS

Thirty children with spastic diplegic CP from both genders participated in this study; their ages were between 6 and 9 years. They were divided randomly into two study groups of equal numbers; the first study group A received the regular physical therapy program besides wearing the AFO for successive three months. The second study group B received the regular physical therapy program besides wearing the GRAFO for successive 3 months. All childrens' balance was evaluated before starting the treatment program and after 3 months by using the Biodex balance system (anteroposterior and mediolateral stability indices).

RESULTS

There were significant improvement of all stability indices in both groups (P < 0.05), with significant difference between groups when comparing post-treatment mean values of the measured indices in favor to study group B (P < 0.05).

CONCLUSION

The GRAFO achieved more balance control in children with spastic diplegic CP compared with solid AFO.

Predictors of gross motor function and activities of daily living in children with cerebral palsy

To determine the influence of selected impairment variables, spasticity, trunk control, upper limb function and selective motor control of the lower limb on gross motor function and activities of daily living in children with cerebral palsy (CP). Seventy children with CP, 40 boys and 30 girls, with age range between 11 and 156 months were recruited in this cross-sectional study. Data on spasticity, selective motor control of the lower limb, upper limb function and trunk control were assessed using modified Ashworth scale (MAS), selective motor control of the lower limb (SCALE), paediatric arm function test, trunk motor control assessment and GMFM88, respectively. Among all the variables assessed, only trunk control significantly predicted gross motor function (beta = 0.880; P < 0.001) and activities of daily living (beta = 0.550; P < 0.05). However, gross motor function and activities of daily living have significant (P < 0.05) negative correlations with spasticity, and positive correlations with selective motor control of the lower limb and trunk control. Trunk control is the most influencing factor on gross motor function and activities of daily living in children with CP. Therefore, achieving trunk control especially in those at GMFCS levels V and VI should be a priority during the rehabilitation of children with CP.

The Effects of Over-Ground Robot-Assisted Gait Training for Children with Ataxic Cerebral Palsy: A Case Report

Poor balance and ataxic gait are major impediments to independent living in ataxic cerebral palsy (CP). Robot assisted-gait training (RAGT) has been shown to improve the postural balance and gait function in children with CP. However, there is no report on the application of RAGT for children with ataxic CP. Here, we report two cases of children with ataxic CP who underwent over-ground RAGT along with conventional therapy for 4 weeks. Outcome measures including the gross motor function measure (GMFM), pediatric balance scale, pediatric reach scale, one-minute walk test, and Timed Up and Go test were assessed before and after the 4-week intervention. Both cases were well adapted to the RAGT system without any significant adverse event. Improvements in the GMFM after RAGT, compared with that in the GMFM, after intensive conventional therapy have been reported previously. It is noteworthy that over-ground RAGT improved areas of the GMFM that did not improve with conventional therapy. In addition, over-ground RAGT with conventional therapy led to improvements in functional balance and walking capacity. These findings suggest that over-ground RAGT is feasible and may be a potential option for enhancing balance and functional walking capacity in children with ataxic CP.

tDCS and motor training in individuals with central nervous system disease: A systematic review

BACKGROUND

Transcranial direct current stimulation (tDCS) is a promising tool for patients with neurological disorders, as it increases cortical excitability, motor learning and functionality. The studies up to date have focused on the tDCS parameters while the effects of the motor training have not yet been fully addressed. The purpose of this study is to present a systematic review of all studies related to tDCS in conjunction with motor training (MT) to improve gait performance, functionality, mobility and balance in individuals with non-progressive central nervous system diseases.

METHODS

Seven databases were searched for articles from inception to October 2018. The search strategy followed Collaboration guidelines. The Physiotherapy Evidence Database (PEDro) Scale and Cochrane Collaboration's tool for assessing the risk of bias were applied to evaluate methodological quality.

RESULTS

Four hundred and sixteen recorded were screened. Ten studies met the inclusion criteria. All studies were randomized controlled trials, two of them had a crossover design and other two were pilot studies. Three paper analyzed children and adolescents with cerebral palsy, seven papers analyzed adults and elderly post stroke. tDCS with MT lead to significant results.

CONCLUSIONS

This review found limited evidence for the use of tDCS with MT for in children with CP and adults post stroke, due to the small number of studies as well as their methodological heterogeneity. In the absence of more robust evidence, further studies with a consistent methodological design are needed to endorse the clinical application of tDCS with motor training.

Effect of robot-assisted gait training on motor functions in adolescent and young adult patients with bilateral spastic cerebral palsy: A randomized controlled trial

BACKGROUND

Robot-assisted gait training (RAGT) allows an intensive gait training in patients with cerebral palsy (CP). There are few evidences on the effectiveness of RAGT in adults with CP.

OBJECTIVE

To assess the effect of RAGT on gross motor function in adolescent and adult patients with bilateral spastic CP and to compare the effect of RAGT with conventional kinesiotherapy.

METHODS

Forty-seven patients (mean age 21.2±5.33 years) with bilateral spastic CP were divided into two groups. Twenty-one patients underwent 20 therapeutic units of RAGT and 26 patients underwent 20 therapeutic units of conventional therapy/training (CON). The following parameters were evaluated before (V1) and after the therapy (V2): dimension A (lying and rolling), B (sitting), C (crawling and kneeling), D (standing), E (walking, running and jumping) of the Gross Motor Function Measure (GMFM-88). In patients in the experimental RAGT group, these parameters were also evaluated 3-4 months later (V3).

RESULTS

Comparing the mean improvements in endpoints in both groups (RAGT vs. CON) after 20 TUs, we observed the statistically significant difference (p < 0.001) and large effect size in all GMFM dimensions and total GMFM improvement in favour of the RAGT group. In RAGT patients, the improvement persisted even 3-4 months after RAGT (p < 0.001).

CONCLUSION

We demonstrated that the intensive RAGT regimen is more effective than conventional therapy in terms of improvements in gross motor functions in adolescent and adult patients with bilateral spastic CP.

Translation, reliability and validity of the Greek functional mobility scale (FMS) for children with cerebral palsy

PURPOSE

To translate and investigate the reliability and validity of the Greek version of the Functional Mobility Scale (FMS).

METHODS

FMS was translated into Greek. Test-retest reliability (Cohen's weighted kappa coefficient, κ_w) and concurrent validity (Spearman's rank correlation coefficient, r_s) of the Greek version of FMS were assessed in children with Cerebral Palsy (CP). Sixty children (mean age 7.82 ± 3.20 years) were recruited. Physical therapists administered the FMS by interviewing parents about their children's mobility status. The Gross Motor Function Classification System (GMFCS) was additionally used for testing concurrent validity.

RESULTS

The translation of the FMS was deemed easy to understand and administer. The Greek FMS was demonstrated to have almost perfect test-retest reliability (κ_w=0.98-1.00), and very strong correlation with the GMFCS (-0.85 ≤ r_s ≤ -0.89, p < 0.001).

CONCLUSIONS

The Greek version of the FMS was shown to be a reliable and valid classification system for CP and can be used with confidence by Greek physical therapists.Implications for rehabilitationThe FMS provides a very simple and practical outcome measure of functional mobility in children with CP.The use of the reliable and valid Greek FMS will enhance the physical therapy assessment process in the Greek population, by offering the feasibility to detect the motor performance changes in children with CP as they grow or following interventions.The current study renders the Greek FMS available for utilization by physical therapists in order to quantify the independent mobility in children with CP.

Advances in cerebral palsy biomarkers

Cerebral palsy (CP), defined as a group of nonprogressive disorders of movement and posture, is the most common cause of severe neurodisability in children. The prevalence of CP is the same across the globe, affecting approximately 17 million people worldwide. Cerebral Palsy is an umbrella term used to describe the disease due to its inherent heterogeneity. For instance, CP has multiple (1) causes; (2) clinical types; (3) patterns of neuropathology on brain imaging and (4) it's associated with several developmental pathologies such as intellectual disability, autism, epilepsy, and visual impairment. Understanding its physiopathology is crucial to developing protective strategies. Despite its importance, there is still insufficient progress in the areas of CP prediction, early diagnosis, treatment, and prevention. Herein we describe the current risk factors and biomarkers used for the diagnosis and prediction of CP. With the advancement in biomarker discovery, we predict that our understanding of the etiopathophysiology of CP will also increase, lending to more opportunities for developing novel treatments and prognosis.

White matter characteristics of motor, sensory and interhemispheric tracts underlying impaired upper limb function in children with unilateral cerebral palsy

This study explored the role of lesion timing (periventricular white matter versus cortical and deep grey matter lesions) and type of corticospinal tract (CST) wiring pattern (contralateral, bilateral, ipsilateral) on white matter characteristics of the CST, medial lemniscus, superior thalamic radiations and sensorimotor transcallosal fibers in children with unilateral cerebral palsy (CP), and examined the association with upper limb function. Thirty-four children (mean age 10 years 7 months ± 2 years 3 months) with unilateral CP underwent a comprehensive upper limb evaluation and diffusion weighted imaging (75 directions, b value 2800). Streamline count, fractional anisotropy and mean diffusivity were extracted from the targeted tracts and asymmetry indices were additionally calculated. Transcranial magnetic stimulation was applied to assess the CST wiring pattern. Results showed a more damaged CST in children with cortical and deep grey matter lesions (N = 10) and ipsilateral CST projections (N = 11) compared to children with periventricular white matter lesions (N = 24; p < 0.02) and contralateral CST projections (N = 9; p < 0.025), respectively. Moderate to high correlations were found between diffusion metrics of the targeted tracts and upper limb function (r = 0.45-0.72; p < 0.01). Asymmetry indices of the CST and sensory tracts could best explain bimanual performance (74%, p < 0.0001) and unimanual capacity (50%, p = 0.004). Adding lesion timing and CST wiring pattern did not further improve the model of bimanual performance, while for unimanual capacity lesion timing was additionally retained (58%, p = 0.0002). These results contribute to a better understanding of the underlying neuropathology of upper limb function in children with unilateral CP and point towards a clinical potential of tractography.

Follow-up of walking quality after end of growth in 28 children with bilateral cerebral palsy

PURPOSE

Assessment of surgical treatments on gait in patients with bilateral cerebral palsy (CP) is often performed in short-term studies. The purpose of this study was to analyze the influence of single-event multilevel surgery (SEMLS) on long-term evolution of gait using gait deviation index (GDI) and walking speed.

METHODS

In all, 28 patients with bilateral CP (Gross Motor Function Classification System I to III) with two clinical gait analyses (CGA) were included (mean age: 9.0 years (sd 2.9) at the first CGA, 19.6 years (sd 4.1) at the last, all of them at skeletal maturity). GDI, walking speed and their changes were calculated. Statistical analysis was performed to observe differences between baseline and follow-up CGA. Pearson's correlations were conducted to evaluate the associations between GDI and walking speed changes with: GDI at baseline and walking speed at baseline. GDI and walking speed evolution have been analyzed for two groups of patients: with and without SEMLS.

RESULTS

Regardless of the treatment, GDI was significantly higher at follow-up CGA (baseline: 73.1 (sd 13.1) versus follow-up: 80.1 (sd 13.2); p = 0.014). Significant negative correlations were found between GDI change and GDI at baseline (r = -0.52; p = 0.004) and between walking speed change and walking speed at the baseline (r = -0.70; p < 0.001). Regarding the group of patients with or without SEMLS, only significant improvement of GDI was found for patients with SEMLS (at baseline: 69.0 (sd 12.1) versus follow-up: 77.8 (sd 11.2); p < 0.05).

CONCLUSION

Analysis at skeletal maturity showed a gait quality maintained for patients without SEMLS and an improvement for patients with SEMLS.

LEVEL OF EVIDENCE

Level III.

Strabismus Is Correlated with Gross Motor Function in Children with Spastic Cerebral Palsy

Purpose: To investigate the correlation between clinical features of strabismus and motor dysfunction classified according to the Gross Motor Function Classification System (GMFCS) in patients with spastic cerebral palsy (CP).Methods: In this retrospective, cross-sectional study in single tertiary medical center, 62 patients who are diagnosed with spastic CP who had an ophthalmic examination between 2006 and 2014 were included. Only patients with vision sufficient to fixate were included and patients with restrictive or paralytic strabismus were excluded. The types of CP were classified as diplegia, hemiplegia, or quadriplegia for distribution of motor impairment. The GMFCS was used to grade gross motor dysfunction, which was then classified as mild (grade 1, 2 and 3) or severe (grade 4 and 5) motor impairment. Strabismus was investigated in terms of direction, constancy, and deviation angle. The relationship between strabismus characteristics and the level of GMFCS and type of CP were assessed.Results: Thirty-eight and 24 patients had mild or severe motor deficit, respectively. Forty patients had strabismus, which was more frequent in patients with severe motor impairment.(P = .014) Exotropia and esotropia occurred with similar frequency. Constant and large-angle strabismus was frequently observed in patients with severe motor impairment.(P < .005, 0.027) The topographical subtype of CP was not related to clinical features of strabismus.Conclusions: The prevalence of strabismus is higher in severe motor impairment. The constancy and angle of strabismus was related to the severity of motor impairment while the topographical subtype of CP has no significant relationship.

Kinetic-based indexes for the functional evaluation of gait in diplegic children: a preliminary report

We evaluated the feasibility of a set of indexes based on ground reaction forces to discriminate between the degree of severity of spastic diplegia, identified via Gross Motor Function Classification System (GMFCS). A stepwise discriminant ordinal regression analysis performed on a sample of 58 children returned a subset of variables related to the ratio between braking and propulsive vertical forces and anteroposterior timings. Rather, parameters concerning bilateral symmetry were poorly discriminating. The relative simplicity of the selected indexes allows for their easy implementation on existing gait analysis applications for screening purposes.

The Immediate Effects of a Dynamic Orthosis on Gait Patterns in Children With Unilateral Spastic Cerebral Palsy: A Kinematic Analysis

This study analyzes the immediate effects of wearing a Therasuit on sagittal plane lower limb angular displacements during gait in children with unilateral spastic cerebral palsy (US-CP). Seven participants (median age = 7.00 years; ranging from 5.83 to 9.00 years) with US-CP, levels I and II of the Gross Motor Function Classification System, were assessed with kinematic gait analysis in three different conditions: (A) Baseline; (B) Therasuit without elastics and (C) Therasuit with elastics. Significant improvements were observed at the hip joint of both lower limbs during most of the gait cycle in participants wearing a Therasuit, including a decrease in the flexion pattern at the initial contact and swing phase in both lower limbs, and an increase in the extension pattern in the paretic lower limb during the stance phase. At the knee joint in the paretic lower limb, significant differences were found between the baseline and Therasuit with elastics conditions on the knee angle at initial contact, and between baseline and both Therasuit conditions on the flexion angle at swing phase. However, the inter-individual variability in kinematic patterns at the knee joint was high. At the ankle joint, decreased plantar flexion at initial contact and increased dorsiflexion during stance and swing phases were observed at the Therasuit with elastics condition, helping to correct the equinus-foot in the paretic lower limb during the whole gait cycle. The Z-values showed large effect sizes particularly for most of the angular hip variables in both lower limbs and for the angular ankle variables in the paretic lower limb. The Therasuit seems to have some positive immediate effects on gait kinematics in children with spastic unilateral cerebral palsy by providing a more functional and safer gait pattern. Future investigations with larger samples are recommended to further support these findings.

Parental Perspectives on Diagnosis and Prognosis of Neonatal Intensive Care Unit Graduates with Cerebral Palsy

OBJECTIVES

To describe how parents of neonatal intensive care unit (NICU) graduates with cerebral palsy (CP) perceive both the accuracy of prognoses provided in the NICU and the timing of their child's diagnosis of CP, and to assess the influence of functional outcome on these perceptions.

STUDY DESIGN

We surveyed parents of NICU graduates with CP about timing and benefit of diagnosis, accuracy of prognosis, and functional abilities of their children. After piloting and validation, CP parent support groups circulated the survey on social media, websites, and email lists. Bivariate relationships between categorical responses to survey questions were assessed with the χ² test, and multivariable logistic regression was performed to identify independent factors associated with perceptions about the timing of diagnosis.

RESULTS

Parents of 463 children were included. Two-thirds (67%) of the children were diagnosed with CP before age 2 years, yet 40% of the respondents felt that diagnosis was made late, and only 11% categorized diagnosis as early. More than one-half (59%) perceived a benefit to diagnosis. There was a significant association between earlier age at diagnosis and greater functional limitations; 24% of parents who recalled being given a prognosis reported that their child functioned as predicted, and 46% reported that their child exceeded expectations. Parents were more likely to believe that children with fewer functional limitations had exceeded expectations.

CONCLUSION

Parents remember prognostic discussions about children who develop CP as underestimating functional outcome. Diagnosis is rarely seen as early and is associated with benefits. These observations suggest that clinicians should aim to diagnose CP early and to maintain guarded optimism about future outcomes. Tools for improved communication are urgently needed.

Is more frequent physical therapy associated with increased gross motor improvement in children with cerebral palsy? A national prospective cohort study

Purpose: To investigate the association between physical therapy frequency and gross motor improvement in children with cerebral palsy (CP).Materials and methods: This is a prospective cohort study of 442 children aged 2-12 years, Gross Motor Function Classification System levels I-V, from the Cerebral Palsy Follow-up Program and the Cerebral Palsy Register of Norway. Outcome was change in reference percentiles for the Gross Motor Function Measure (GMFM-66) between two subsequent assessments (N = 1056) analyzed in a linear mixed model.Results: It was a dose response association between physical therapy frequency and gross motor improvement. Mean change was 4.2 (95% CI: 1.4-7.1) percentiles larger for physical therapy 1-2 times per week and 7.1 (95% CI: 2.6-11.6) percentiles larger for physical therapy >2 times per week, compared to less frequent physical therapy when analyzed in a multivariable model including multiple child and intervention factors. The only statistically significant confounder was number of contractures which was negatively associated with gross motor improvement.Conclusions: When gross motor improvement is a goal for children with CP, more frequent physical therapy should be considered.Implications for rehabilitationIn general, the gross motor development of Norwegian children with cerebral palsy was as expected according to the reference percentiles for the GMFM-66.When gross motor improvement is a goal for children with cerebral palsy, high-frequency physical therapy should be considered.Contractures should be addressed in order to optimize gross motor improvement for children with cerebral palsy.

Interventions to Improve or Maintain Lower-Limb Function Among Ambulatory Adolescents with Cerebral Palsy: A Cross-Sectional Survey of Current Practice in the UK

OBJECTIVES

To describe physiotherapy management to improve or maintain lower-limb function among adolescents with cerebral palsy, classified in Gross Motor Function Classification System levels I-III, in the United Kingdom (UK).

METHODS

A list of interventions was identified using a nominal group technique and developed into a survey, which was distributed to approximately 2,100 pediatric physiotherapists in the UK through the Association of Pediatric Chartered Physiotherapists and a private physiotherapy clinic in London between April and June 2015. One-hundred and thirty-five physiotherapists completed the survey. Survey respondents indicated how frequently they used each intervention (i.e., "frequently," "sometimes," "rarely," and "never") in the past year.

RESULTS

Provision of explanations to the child, liaison with families, liaison with health professionals, provision of advice to schools, and stretching were the most frequently used interventions with 90%, 90%, 86%, 79%, and 76% of respondents, respectively, reporting that they frequently used each. The interventions most commonly reported as "never" used were conductive education (88%), MOVE programme (85%), functional electrical stimulation (82%), body-weight supported treadmill training (80%), and rebound therapy (71%).

CONCLUSIONS

This study suggests that a large number of interventions are used by physiotherapists in the United Kingdom to improve or maintain lower-limb function among adolescents with CP, not all of which are evidence-based.

Socioeconomic Status and Pediatric Neurologic Disorders: Current Evidence

Socioeconomic status (SES) is an important risk factor for many neurological disorders and a determinant of health outcomes and quality of life, especially for individuals with neurologic disorders and developmental disabilities. This article focuses on the relationship between SES and pediatric epilepsy, cerebral palsy, autism spectrum disorder, and intellectual disability. Disparities in the prevalence and long-term impact of SES on functioning in persons with disabilities are observed worldwide. Clinicians can use the information presented in the article to target early identification and interventions for improving outcomes in populations most at risk for these disorders and for poor health, social, and economic outcomes.

Functional Capacity and Self-Esteem of People With Cerebral Palsy

OBJECTIVE

We assessed whether functional capacity predicts self-esteem in people with cerebral palsy (CP).

METHOD

We conducted a cross-sectional observational study of 108 people with CP, ages 16-65 yr, who were residents of Spain. Self-esteem was captured using the Rosenberg Self-Esteem Scale (RSES), and functional capacity using the Barthel Index (BI). Sociodemographic characteristics were recorded. The relationship between the RSES score and the BI score was analyzed using linear regression.

RESULTS

RSES scores increased significantly as BI scores increased (regression coefficient = 0.047, 95% confidence interval [0.017, 0.078], p = .003). People with a higher level of education, active employment, and independent living arrangements tended to have better functional capacity and higher self-esteem.

CONCLUSION

Greater functional capacity predicted higher self-esteem; this effect is probably partly mediated by education, employment, and living arrangements.

Factors Associated with Enhanced Gross Motor Progress in Children with Cerebral Palsy: A Register-Based Study

AIM

To examine associations between interventions and child characteristics; and enhanced gross motor progress in children with cerebral palsy (CP).

METHODS

Prospective cohort study based on 2048 assessments of 442 children (256 boys, 186 girls) aged 2-12 years registered in the Cerebral Palsy Follow-up Program and the Cerebral Palsy Register of Norway. Gross motor progress estimates were based on repeated measures of reference percentiles for the Gross Motor Function Measure (GMFM-66) in a linear mixed model. Mean follow-up time: 2.9 years.

RESULTS

Intensive training was the only intervention factor associated with enhanced gross motor progress (mean 3.3 percentiles, 95% CI: 1.0, 5.5 per period of ≥3 sessions per week and/or participation in an intensive program). Gross motor function was on average 24.2 percentiles (95% CI: 15.2, 33.2) lower in children with intellectual disability compared with others. Except for eating problems (-10.5 percentiles 95% CI: -18.5, -2.4) and ankle contractures by age (-1.9 percentiles 95% CI: -3.6, -0.2) no other factors examined were associated with long-term gross motor progress.

CONCLUSIONS

Intensive training was associated with enhanced gross motor progress over an average of 2.9 years in children with CP. Intellectual disability was a strong negative prognostic factor. Preventing ankle contractures appears important for gross motor progress.

A Novel Mobility Device to Improve Walking for a Child With Cerebral Palsy

PURPOSE

To describe the use and outcomes associated with the Upsee in conjunction with Kinesiotape for a child with cerebral palsy.

DESCRIPTIONS

The Upsee and Kinesiotaping were implemented for 24 weeks with a 31-month-old child with cerebral palsy, Gross Motor Function Classification System level III.

OUTCOMES

She progressed from walking with maximal assistance and extensive gait deviations to walking with supervision with a walker on level surfaces with improved gait. Genu recurvatum, heel strike, scissoring, hip extension, foot placement, step length, and stiff knee in swing improved on the basis of videotaped analyses. The Gross Motor Function Measure-66 improved by 11.4.

CONCLUSIONS AND WHAT THIS CASE ADDS

The Upsee is a clinically feasible approach for gait impairments in children through providing increased opportunities for walking while supporting biomechanical alignment. Upsee effectiveness with and without taping is an area for future study.

Self-efficacy of physical education teachers in including students with cerebral palsy in their classes

Children with cerebral palsy (CP) are often mainstreamed into the general education system, but are likely to be excluded from physical education (PE) classes. A questionnaire was constructed and utilized to measure PE teachers' self-efficacy (SE) toward inclusion of students with CP in each of three mobility categories (independent, using assistive devices, using wheelchair mobility) and the impact of experience and training on teachers' SE. Participants in the study were 121 PE teachers from different parts of Israel (mean age: 41.02±9.33 years; range: 25.00-59.00 years). Exploratory factor analysis was used to determine the structure of the sub-scales' factors' structure and Cronbach's Alpha reliability was satisfactory (range 0.872-0.941). Independent t-tests were calculated in order to compare the SE of teachers with and without adapted PE experience. Repeated Analysis of Variance was performed to measure within-group differences in SE. Results revealed that the PE teachers' SE in teaching students who use mobility assistive devices or wheelchairs was significantly lower compared to teaching those who walk and run unaided (F=19.11; p<0.001). The teachers' SE towards including CP children who independently ambulate was influenced (p<0.05; d=0.94) by the teacher's experience (elementary school practicum). SE in the mobility with assistive device group was also significantly influenced (p<0.05; d=0.1) by teaching experience (previous experience and having a specialization in adapted PE). Finally, SE when teaching the wheelchair mobility group was influenced by having an adapted PE specialization (p<0.05; d=0.82). Specialized training in this particular area should be enhanced to increase teachers' SE and enable greater participation of children with CP in general physical education classes.

Therapeutic effects of an anti-gravity treadmill (AlterG) training on gait and lower limbs kinematics and kinetics in children with cerebral palsy

We aimed to investigate the effects of the lower body weight support treadmill (AlterG) training on kinetics and kinematics of the lower extremities in children with cerebral palsy (CP). We provided a 45-minute training program, 3 times a week for 8 weeks. AlterG can support the subject's weight up to 70% so that the subject will be able to walk more comfortably to reach a more correct walking pattern. The kinematics and kinetics were evaluated using an isokinetic dynamometer. The locomotion parameters were assessed in the gait laboratory. Subjects performance was evaluated at four time points: baseline (prior to training), 1 and 2 months after the beginning of training, and one month after the end of the training (as a follow-up evaluation). The results showed that the major gait, kinematic, and kinetic parameters improved after the AlterG training and were persistent. These findings suggest that the AlterG training can be considered as a therapeutic tool for improving the lower limb performance and locomotion in children with CP.

Improved Walking Capacity and Muscle Strength After Functional Power-Training in Young Children With Cerebral Palsy

Background. Strength training programs for children with cerebral palsy (CP) showed inconclusive evidence for improving walking, despite improvements in strength. Recent studies have suggested that strength training with high movement velocity is more effective for improving walking than traditional resistance training. Objective. The purpose of this study was to evaluate the effect of functional high-velocity resistance training (power-training) to improve muscle strength and walking capacity of children with CP. Method. Twenty-two children with spastic CP participated (13 bilateral, Gross Motor Function Classification System [GMFCS] level I [n = 10] and II [n = 12], 7.5 years [SD 1.8, range 4-10 years]). Within-subjects changes in a 14-weeks usual care period were compared with changes in a 14-week functional power-training period (in groups, 3×/wk). Outcome measures were the muscle power sprint test (MPST), 1-minute walk test (1MWT), 10-m shuttle run test (SRT), gross motor function (GMFM-66), isometric strength of lower-limb muscles and dynamic ankle plantar flexor strength. Results. Changes during the training period were significantly larger than changes in the usual care period for all outcome measures ( P < .05). Large improvements were found during the training period for walking capacity (ΔMPST [mean]: 27.6 W [95%CI 15.84-39.46, 83% increase], Δ1MWT: 9.4 m [95% CI 4.17-14.68, 13%], ΔSRT: 4.2 [95%CI 2.57-5.83, 56%], ΔGMFM-66: 5.5 [95% CI 3.33-7.74, 7%]) and muscle strength (18%-128%), while outcomes remained stable in the usual care period. Conclusions. The results indicate that functional power-training is an effective training for improving walking capacity in young children with cerebral palsy.

Effectiveness of Functional Power Training on Walking Ability in Young Children With Cerebral Palsy: Study Protocol of a Double-Baseline Trial

PURPOSE

To evaluate the effect of functional high-velocity resistance (power) training to improve walking ability of young children with cerebral palsy.

METHODS

Twenty-two children with bi- or unilateral spastic cerebral palsy, Gross Motor Function Classification System levels I and II, aged 4 to 10 years will be recruited. A double-baseline design will be used to compare a 14-week functional power training (3 times a week) program with a 14-week usual care period and a 14-week follow-up period. The power exercises will be loaded and performed at 50% to 70% of the maximum unloaded speed. Load will be increased when exercises are performed faster than 70% of the unloaded speed. Primary outcomes will be sprinting capacity (15-m Muscle Power Sprint Test) and goal attainment scaling score of walking-related treatment goals. Secondary outcomes will be walking speed (1-min walk test), endurance (10-m shuttle run test), gross motor function, lower-limb strength, and parent-reported mobility.

Exercise interventions for cerebral palsy

BACKGROUND

Cerebral palsy (CP) is a neurodevelopmental disorder resulting from an injury to the developing brain. It is the most common form of childhood disability with prevalence rates of between 1.5 and 3.8 per 1000 births reported worldwide. The primary impairments associated with CP include reduced muscle strength and reduced cardiorespiratory fitness, resulting in difficulties performing activities such as dressing, walking and negotiating stairs.Exercise is defined as a planned, structured and repetitive activity that aims to improve fitness, and it is a commonly used intervention for people with CP. Aerobic and resistance training may improve activity (i.e. the ability to execute a task) and participation (i.e. involvement in a life situation) through their impact on the primary impairments of CP. However, to date, there has been no comprehensive review of exercise interventions for people with CP.

OBJECTIVES

To assess the effects of exercise interventions in people with CP, primarily in terms of activity, participation and quality of life. Secondary outcomes assessed body functions and body structures. Comparators of interest were no treatment, usual care or an alternative type of exercise intervention.

SEARCH METHODS

In June 2016 we searched CENTRAL, MEDLINE, Embase, nine other databases and four trials registers.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs of children, adolescents and adults with CP. We included studies of aerobic exercise, resistance training, and 'mixed training' (a combination of at least two of aerobic exercise, resistance training and anaerobic training).

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles, abstracts and potentially relevant full-text reports for eligibility; extracted all relevant data and conducted 'Risk of bias' and GRADE assessments.

MAIN RESULTS

We included 29 trials (926 participants); 27 included children and adolescents up to the age of 19 years, three included adolescents and young adults (10 to 22 years), and one included adults over 20 years. Males constituted 53% of the sample. Five trials were conducted in the USA; four in Australia; two in Egypt, Korea, Saudi Arabia, Taiwan, the Netherlands, and the UK; three in Greece; and one apiece in India, Italy, Norway, and South Africa.Twenty-six trials included people with spastic CP only; three trials included children and adolescents with spastic and other types of CP. Twenty-one trials included people who were able to walk with or without assistive devices, four trials also included people who used wheeled mobility devices in most settings, and one trial included people who used wheeled mobility devices only. Three trials did not report the functional ability of participants. Only two trials reported participants' manual ability. Eight studies compared aerobic exercise to usual care, while 15 compared resistance training and 4 compared mixed training to usual care or no treatment. Two trials compared aerobic exercise to resistance training. We judged all trials to be at high risk of bias overall.We found low-quality evidence that aerobic exercise improves gross motor function in the short term (standardised mean difference (SMD) 0.53, 95% confidence interval (CI) 0.02 to 1.04, N = 65, 3 studies) and intermediate term (mean difference (MD) 12.96%, 95% CI 0.52% to 25.40%, N = 12, 1 study). Aerobic exercise does not improve gait speed in the short term (MD 0.09 m/s, 95% CI -0.11 m/s to 0.28 m/s, N = 82, 4 studies, very low-quality evidence) or intermediate term (MD -0.17 m/s, 95% CI -0.59 m/s to 0.24 m/s, N = 12, 1 study, low-quality evidence). No trial assessed participation or quality of life following aerobic exercise.We found low-quality evidence that resistance training does not improve gross motor function (SMD 0.12, 95% CI -0.19 to 0.43, N = 164, 7 studies), gait speed (MD 0.03 m/s, 95% CI -0.02 m/s to 0.07 m/s, N = 185, 8 studies), participation (SMD 0.34, 95% CI -0.01 to 0.70, N = 127, 2 studies) or parent-reported quality of life (MD 12.70, 95% CI -5.63 to 31.03, n = 12, 1 study) in the short term. There is also low-quality evidence that resistance training does not improve gait speed (MD -0.03 m/s, 95% CI -0.17 m/s to 0.11 m/s, N = 84, 3 studies), gross motor function (SMD 0.13, 95% CI -0.30 to 0.55, N = 85, 3 studies) or participation (MD 0.37, 95% CI -6.61 to 7.35, N = 36, 1 study) in the intermediate term.We found low-quality evidence that mixed training does not improve gross motor function (SMD 0.02, 95% CI -0.29 to 0.33, N = 163, 4 studies) or gait speed (MD 0.10 m/s, -0.07 m/s to 0.27 m/s, N = 58, 1 study) but does improve participation (MD 0.40, 95% CI 0.13 to 0.67, N = 65, 1 study) in the short-term.There is no difference between resistance training and aerobic exercise in terms of the effect on gross motor function in the short term (SMD 0.02, 95% CI -0.50 to 0.55, N = 56, 2 studies, low-quality evidence).Thirteen trials did not report adverse events, seven reported no adverse events, and nine reported non-serious adverse events.

AUTHORS' CONCLUSIONS

The quality of evidence for all conclusions is low to very low. As included trials have small sample sizes, heterogeneity may be underestimated, resulting in considerable uncertainty relating to effect estimates. For children with CP, there is evidence that aerobic exercise may result in a small improvement in gross motor function, though it does not improve gait speed. There is evidence that resistance training does not improve gait speed, gross motor function, participation or quality of life among children with CP.Based on the evidence available, exercise appears to be safe for people with CP; only 55% of trials, however, reported adverse events or stated that they monitored adverse events. There is a need for large, high-quality, well-reported RCTs that assess the effectiveness of exercise in terms of activity and participation, before drawing any firm conclusions on the effectiveness of exercise for people with CP. Research is also required to determine if current exercise guidelines for the general population are effective and feasible for people with CP.

Use of powered mobility for a young adult with profound and multiple learning disabilities: a practice analysis

Statement of context

Powered mobility has reported benefits as a learning tool for individuals limited in independent mobility. The majority of literature focuses on early years populations and there remains a need to address powered mobility for adults with profound and multiple learning disabilities. This article explores the experience of switch-operated powered mobility training for one young adult with profound and multiple learning disabilities.

Critical reflection on practice

Powered mobility provided a motivating medium through which previously unseen skills, such as upper limb use, were demonstrated. Use of switches, rather than typically used joysticks, allowed successful participation.

Implication for practice

Providing the right equipment, environment and appropriate challenge for an individual can facilitate unexpected achievement.

Corticoreticular tract lesion in children with developmental delay presenting with gait dysfunction and trunk instability

The corticoreticular tract (CRT) is known to be involved in walking and postural control. Using diffusion tensor tractography (DTT), we investigated the relationship between the CRT and gait dysfunction, including trunk instability, in pediatric patients. Thirty patients with delayed development and 15 age-matched, typically-developed (TD) children were recruited. Fifteen patients with gait dysfunction (bilateral trunk instability) were included in the group A, and the other 15 patients with gait dysfunction (unilateral trunk instability) were included in the group B. The Growth Motor Function Classification System, Functional Ambulation Category scale, and Functional Ambulation Category scale were used for measurement of functional state. Fractional anisotropy, apparent diffusion coefficient, fiber number, and tract integrity of the CRT and corticospinal tract were measured. Diffusion parameters or integrity of corticospinal tract were not significantly different in the three study groups. However, CRT results revealed that both CRTs were disrupted in the group A, whereas CRT disruption in the hemispheres contralateral to clinical manifestations was observed in the group B. Fractional anisotropy values and fiber numbers in both CRTs were decreased in the group A than in the group TD. The extents of decreases of fractional anisotropy values and fiber numbers on the ipsilateral side relative to those on the contralateral side were greater in the group B than in the group TD. Functional evaluation data and clinical manifestations were found to show strong correlations with CRT status, rather than with corticospinal tract status. These findings suggest that CRT status appears to be clinically important for gait function and trunk stability in pediatric patients and DTT can help assess CRT status in pediatric patients with gait dysfunction.

PLAY HANDS PROTECTIVE GLOVES: TECHNICAL NOTE ON DESIGN AND CONCEPT

Cerebral Palsy (CP) is the leading cause of childhood motor disability, with a global incidence of 1.6 to 2.5/1,000 live births. Approximately 23% of children with CP are dependent upon assistive technologies. Some children with developmental disabilities have self-injurious behaviors such as finger biting but also have therapeutic needs. The purpose of this technical note is to describe design considerations for a protective glove and finger covering that maintains finger dexterity for children who exhibit finger and hand chewing (dermatophagia) and require therapeutic range of motion and may benefit from sensory stimulation resulting from constant contact between glove and skin. Protecting Little and Adolescent Youth (PLAY) Hands are protective gloves for children with developmental disorders such as CP who injure themselves by biting their hands due to pain or sensory issues. PLAY Hands will be cosmetically appealing gloves that provide therapeutic warmth, tactile sensory feedback, range of motion for donning/ doffing, and protection to maximize function and quality of life for families of children with developmental disorders. The technology is either a per-finger protective orthosis or an entire glove solution designed from durable 3D-printed biodegradable/bioabsorbable materials such as thermoplastics. PLAY Hands represent a series of protective hand wear interventions in the areas of self-mutilating behavior, kinematics, and sensation. They will be made available in a range of protective iterations from single- or multi-digit finger orthoses to a basic glove design to a more structurally robust and protective iteration. To improve the quality of life for patients and caregivers, they are conceptualized to be cosmetically appealing, protective, and therapeutic.

Prevalence of Cerebral Palsy among 8-Year-Old Children in 2010 and Preliminary Evidence of Trends in Its Relationship to Low Birthweight

BACKGROUND

The public health objective for cerebral palsy (CP) in the United States is to reduce the percentage of children with CP who were born low birthweight (LBW, <2500 g) by 10% between 2006 and 2020. This study reports the prevalence of CP in a constant surveillance area for the years 2006, 2008, and 2010 and describes initial progress towards the CP public health objective.

METHODS

Data on children with CP at age 8 years were ascertained by the Autism and Developmental Disabilities Monitoring (ADDM) Network, a population-based surveillance system that monitored CP in four areas of the United States.

RESULTS

CP prevalence in 2010 was 2.9 per 1000 [95% confidence interval (CI) 2.6, 3.2], down from 3.5 (95% CI 3.2, 3.9) in the same surveillance area in 2006. Among CP cases with no documented postneonatal aetiology, 49.1% (95% CI 42.9, 55.2) were born LBW in 2010 compared with 54.3% (95% CI 48.4, 60.1) in 2006. In 2010, 28.1% (95% CI 22.9, 30.4) were born very low birthweight (VLBW, <1500 g) compared with 35.4% (95% CI 30.0, 41.2) in 2006. The relative risks for associations between CP and both LBW and VLBW also declined, though not significantly, during the study period.

CONCLUSIONS

Declines in the associations between CP and LBW categories may have contributed to declines during the study period in both the prevalence of CP and the percentage of children with CP who were born LBW or VLBW. Ongoing monitoring of these trends is warranted.

Discriminant ability of the Infant Neurological International Battery (INFANIB) as a screening tool for the neurological follow-up of high-risk infants in Colombia

AIM

The aim of this study was to assess the discriminative ability of the Infant Neurological International Battery (INFANIB), applied at 3, 6 and 9 months of corrected age (CA), on neurological outcomes at 1 year of CA.

METHOD

An observational analytic study was conducted on a cohort of 5857 infants, followed up to 1 year of CA in a Kangaroo Mother Care programme from 1993 to 2010 in Bogotá, Colombia. Infants were included if they had two complete INFANIB results at 3 or 6 or 9 months of CA and at 12 months of CA, including the Griffiths Scale. The outcome was defined as the presence of a neurological abnormality, as evidenced by the results of both the INFANIB and Griffiths Scale.

RESULTS

The sensitivity of the INFANIB at 3 months was 62.2%, and specificity was 76.1%, with a receiver operating characteristic (ROC) area of 0.69. At 6 months, the results were 77.5% for sensitivity and 74.4% for specificity (ROC 0.76), and at 9 months, they were 77.2% for sensitivity and 91.1% for specificity (ROC 0.84).

CONCLUSION

The INFANIB was an appropriate neurological screening test with regard to determining which Colombian infants would benefit from a timely intervention for neuromotor disorders.

Home-Based Versus Laboratory-Based Robotic Ankle Training for Children With Cerebral Palsy: A Pilot Randomized Comparative Trial

OBJECTIVE

To examine the outcomes of home-based robot-guided therapy and compare it to laboratory-based robot-guided therapy for the treatment of impaired ankles in children with cerebral palsy.

DESIGN

A randomized comparative trial design comparing a home-based training group and a laboratory-based training group.

SETTING

Home versus laboratory within a research hospital.

PARTICIPANTS

Children (N=41) with cerebral palsy who were at Gross Motor Function Classification System level I, II, or III were randomly assigned to 2 groups. Children in home-based and laboratory-based groups were 8.7±2.8 (n=23) and 10.7±6.0 (n=18) years old, respectively.

INTERVENTIONS

Six-week combined passive stretching and active movement intervention of impaired ankle in a laboratory or home environment using a portable rehabilitation robot.

MAIN OUTCOME MEASURES

Active dorsiflexion range of motion (as the primary outcome), mobility (6-minute walk test and timed Up and Go test), balance (Pediatric Balance Scale), Selective Motor Control Assessment of the Lower Extremity, Modified Ashworth Scale (MAS) for spasticity, passive range of motion (PROM), strength, and joint stiffness.

RESULTS

Significant improvements were found for the home-based group in all biomechanical outcome measures except for PROM and all clinical outcome measures except the MAS. The laboratory-based group also showed significant improvements in all the biomechanical outcome measures and all clinical outcome measures except the MAS. There were no significant differences in the outcome measures between the 2 groups.

CONCLUSIONS

These findings suggest that the translation of repetitive, goal-directed, biofeedback training through motivating games from the laboratory to the home environment is feasible. The benefits of home-based robot-guided therapy were similar to those of laboratory-based robot-guided therapy.

Evaluation and management of crouch gait

PURPOSE OF REVIEW

Crouch gait is defined as excessive ankle dorsiflexion, knee and hip flexion during the stance phase. This gait disorder is common among patients with cerebral palsy. The present article brings an up-to-date literature review on the pathoanatomy, natural history, and treatment of this frequent gait abnormality.

RECENT FINDINGS

Hamstrings are often not shortened in patients with crouch. Patella alta must be addressed if surgery is performed. Surgical correction of joint contractures and lever arm dysfunction can be effectively achieved through a single-event multilevel surgery.

SUMMARY

Crouch gait is a common gait deviation, often seen among ambulatory diplegic and quadriplegic patients, once they reach the pubertal spurt, when weak muscles can no longer support a toe walking pattern because of rapidly increased weight. This form of gait is highly ineffective and might compromise walking ability over time. The anterior knee is overloaded; pain, extensor mechanism failure, and arthritis might develop. Its progressive nature often requires surgical intervention. The cause of crouch gait is multifactorial, and surgery should be tailored to meet the individual's specific anatomic and physiologic abnormalities.

Benefits and Enjoyment of a Swimming Intervention for Youth With Cerebral Palsy: An RCT Study

PURPOSE

To investigate enjoyment and specific benefits of a swimming intervention for youth with cerebral palsy (CP).

METHODS

Fourteen youth with CP (aged 7 to 17 years, Gross Motor Function Classification System levels I to III) were randomly assigned to control and swimming groups. Walking ability, swimming skills, fatigue, and pain were assessed at baseline, after a 10-week swimming intervention (2/week, 40-50 minutes) or control period, after a 5-week follow-up and, for the intervention group, after a 20-week follow-up period. The level of enjoyment of each swim-session was assessed.

RESULTS

Levels of enjoyment were high. Walking and swimming skills improved significantly more in the swimming than in the control group (P = .043; P = .002, respectively), whereas fatigue and pain did not increase. After 20 weeks, gains in walking and swimming skills were retained (P = .017; P = .016, respectively).

CONCLUSION

We recommend a swimming program for youth with CP to complement a physical therapy program.

Lower Extremity Handheld Dynamometry Strength Measurement in Children With Cerebral Palsy

PURPOSE

The purpose of this study was to evaluate the evidence on reliability of handheld dynamometry protocols to quantify maximal isometric strength of the muscles of the lower extremities of children with cerebral palsy.

METHODS

A systematic search of Cochrane, MEDLINE, CINAHL, and PubMed up to December 2013 and best-evidence synthesis were performed.

RESULTS

Seven eligible studies were identified. Best-evidence synthesis revealed "unknown" to "moderate" evidence. Intraclass correlation coefficient values were "positive" for most muscle groups for intrarater reliability and showed mixed results for interrater reliability.

CONCLUSIONS

Because of small sample sizes (10-25) in all included studies, the final level of evidence remains "unknown." Reliability data obtained in the included studies of handheld dynamometry in children with cerebral palsy are promising, despite low levels of evidence. When these protocols are applied very carefully, they may prove relevant to different clinical settings.

Relationship of Strength, Weight, Age, and Function in Ambulatory Children With Cerebral Palsy

BACKGROUND

The natural history of ambulatory function in individuals with cerebral palsy (CP) consists of deterioration over time. This is thought to be due, in part, to the relationship between strength and weight, which is postulated to become less favorable for ambulation with age.

METHODS

The study design was prospective, case series of 255 subjects, aged 8 to 19 years, with diplegic type of CP. The data analyzed for the study were cross-sectional. Linear regression was used to predict the rate of change in lower extremity muscle strength, body weight, and strength normalized to weight (STR-N) with age. The cohort was analyzed as a whole and in groups based on functional impairment as reflected by Gross Motor Function Classification System (GMFCS) level.

RESULTS

Strength increased significantly over time for the entire cohort at a rate of 20.83 N/y (P=0.01). Weight increased significantly over time for the entire cohort at a rate of 3.5 kg/y (P<0.0001). Lower extremity STR-N decreased significantly over time for the entire cohort at a rate of 0.84 N/kg/y (P<0.0001). The rate of decline in STR-N (N/kg/y) was comparable among age groups of the children in the study group. There were no significant differences in the rate of decline of STR-N (N/kg/y) among GMFCS levels. There was a 90% chance of independent ambulation (GMFCS levels I and II) when STR-N was 21 N/kg (49% predicted relative to typically developing children).

DISCUSSION

The results of this study support the longstanding clinically based observation that STR-N decreases with age in children with CP. This decrease occurs throughout the growing years, and across GMFCS levels I to III. Independent ambulation becomes less likely as STR-N decreases. This information can be used to support the rationale, and provide guidelines, for a range of interventions designed to promote ambulation in children with CP.

The use of instrumented gait analysis for individually tailored interdisciplinary interventions in children with cerebral palsy: a randomised controlled trial protocol

Background

Children with cerebral palsy (CP) often have an altered gait. Orthopaedic surgery, spasticity management, physical therapy and orthotics are used to improve the gait. Interventions are individually tailored and are planned on the basis of clinical examinations and standardised measurements to assess walking (‘care as usual’). However, these measurements do not describe features in the gait that reflect underlying neuro-musculoskeletal impairments. This can be done with 3-dimensional instrumented gait analysis (IGA). The aim of this study is to test the hypothesis that improvements in gait following individually tailored interventions when IGA is used are superior to those following ‘care as usual’.

Methods/Design

A prospective, single blind, randomised, parallel group study will be conducted. Children aged 5 to 8 years with spastic CP, classified at Gross Motor Function Classification System levels I or II, will be included. The interventions under investigation are: 1) individually tailored interdisciplinary interventions based on the use of IGA, and 2) ‘care as usual’. The primary outcome is gait measured by the Gait Deviation Index. Secondary outcome measures are: walking performance (1-min walk test) and patient-reported outcomes of functional mobility (Pediatric Evaluation of Disability Inventory), health-related quality of life (The Pediatric Quality of Life Inventory Cerebral Palsy Module) and overall health, pain and participation (The Pediatric Outcome Data Collection Instrument). The primary endpoint for assessing the outcome of the two interventions will be 52 weeks after start of intervention. A follow up will also be performed at 26 weeks; however, exclusively for the patient-reported outcomes.

Discussion

To our knowledge, this is the first randomised controlled trial comparing the effects of an individually tailored interdisciplinary intervention based on the use of IGA versus ‘care as usual’ in children with CP. Consequently, the study will provide novel evidence for the use of IGA.

Trial registration

Trial registration: ClinicalTrials.gov NCT02160457. Registered June 2, 2014.

Early childhood constraint therapy for sensory/motor impairment in cerebral palsy: a randomised clinical trial protocol

INTRODUCTION

Cerebral palsy (CP) is the most common physical disability in childhood. It is a disorder resulting from sensory and motor impairments due to perinatal brain injury, with lifetime consequences that range from poor adaptive and social function to communication and emotional disturbances. Infants with CP have a fundamental disadvantage in recovering motor function: they do not receive accurate sensory feedback from their movements, leading to developmental disregard. Constraint-induced movement therapy (CIMT) is one of the few effective neurorehabilitative strategies shown to improve upper extremity motor function in adults and older children with CP, potentially overcoming developmental disregard.

METHODS AND ANALYSIS

This study is a randomised controlled trial of children 12-24 months corrected age studying the effectiveness of CIMT combined with motor and sensory-motor interventions. The study population will comprise 72 children with CP and 144 typically developing children for a total of N=216 children. All children with CP, regardless of group allocation will continue with their standard of care occupational and physical therapy throughout the study. The research material collected will be in the form of data from high-density array event-related potential scan, standardised assessment scores and motion analysis scores.

ETHICS AND DISSEMINATION

The study protocol was approved by the Institutional Review Board. The findings of the trial will be disseminated through peer-reviewed journals and scientific conferences.

TRIAL REGISTRATION NUMBER

NCT02567630.